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ES-3101 Rev. 05-07 State of Kansas Department for Children and Families Economic and Employment Services RELEASE OF INFORMATION AND LIABILITY Case Name: Case Number: SECTION I: PERMISSION TO OBTAIN

How to fill out release of information and

How to Fill Out Release of Information:

1. Begin by obtaining the necessary release of information form. This can typically be obtained from the healthcare provider or organization that requires the release.
2. Carefully read through the form to understand the specific information that will be released and to whom it will be released. It is essential to be clear about the purpose and scope of the release.
3. Fill in your personal information accurately, including your full name, date of birth, social security number (if required), and contact information. Providing correct information is crucial to ensure the release is valid.
4. Identify the specific healthcare provider or organization that you are authorizing to release the information. Include their name, contact information, and the type of information to be released (e.g., medical records, test results, treatment history).
5. Specify the purpose for which the information will be released. It could be for personal use, for insurance purposes, for legal proceedings, or for another legitimate reason. Clearly state the purpose to avoid any potential confusion.
6. Determine the timeframe for which the release is valid. You can specify a specific date range or indicate that the release is valid until revoked in writing.
7. Review the release form thoroughly, ensuring all information is accurate and complete. Check for any errors or omissions before signing and dating the form.
8. If required, have the release form witnessed or notarized. Some organizations may require additional verification to ensure the authenticity of the release.
9. Keep a copy of the completed release form for your records before submitting it to the appropriate healthcare provider or organization.

Who Needs Release of Information:

1. Individuals seeking to transfer their medical records to a new healthcare provider may need a release of information. This allows their previous provider to release their records to the new provider.
2. Patients who want to share their medical information with a family member, close friend, or caregiver may require a release of information. This can be necessary when the patient is unable to access or share their records independently.
3. Insurance companies may require a release of information from policyholders to access their medical records. This is typically needed to process claims or determine coverage eligibility.
4. Attorneys and legal professionals may request a release of information to obtain medical records relevant to a legal case or proceeding.
5. Researchers and academic institutions may need a release of information to access medical records for scientific research or educational purposes, ensuring proper privacy protections are in place.

Regardless of the specific need, it is crucial to follow the appropriate steps and guidelines when filling out and submitting a release of information form. This ensures the privacy and confidentiality of your personal health information while allowing for necessary sharing when authorized.

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